price assigned to a unit of medical or health service, such as a visit to a physician or a day in the hospital. The charge for a service may be unrelated to the actual cost of providing the service

Block grant

fixed amount of money given or allocated for a specific purpose, such as a transfer of governmental funds to cover health services

Claim

itemized statement of healthcare services and their costs provided by a hospital, physician's office or other healthcare provider

this is submitted for reimbursement

Third party

usually used in context of an insurance company (Blue Cross/Blue Shield) or healthcare program (Medicaid) that reimburses healthcare providers (second party) and/or patients (first party) for the delivery of medical services

Fee schedule

a method of reimbursement through which providers retrospectively receive payment based on either billed charges for services provided or on annually updated fee schedules; also called fee-for-service reimbursement

Refined case-based payment methods

case-based payment method enhanced to include patients from all age groups or from rgions of the world with varying mixes of diseases and differing patterns of healthcare delivery

MS-DRG

Medicare severity diagnosis-related groups

US Government's 2007 revision of DRG system and is considered to be a better accounting for the severity of illness and resource consumption

CC

complications/comorbidities

complication: a medical condition that arises during an inpatient hospitalization

comorbidity: a medical condition that coexists with the primary cause for hospitalization and affects the patient's treatment and length of stay

ICD-9

International Classification of Diseases, Ninth Revision - a classification system used in the US to report morbidity and mortality information

ICD-10

International Classification of Diseases, Tenth Revision - planned replacement for ICD-9, parts I and II, developed to contain more codes and allow greater specificity

CPT

Current Procedural Terminology - comprehensive, descriptive list of tems and numeric codes used for reporting diagnostic and therapeutic procedures and other medical services performed by physicians; published and updated annually by the AMA

HCPCS, Level II

Healthcare Common Procedure Coding System - alphanumeric classification system that identifies healthcare procedures, equipment and supplies for claim submission purposes - Level II codes for equipment, supplies and services NOT covered by CPT, as well as modifiers that can be used with all levels of codes. Developed by CMS

Undercoding

Well...it's fradulent. Or abusive. But it's not unbundling (using multiple codes to describe individual steps of a procedure rather than using the single code that describes them all) UPCODING is the practice of assigning a diagnosis or procedure code specifically for the purpose of obtaining a higher level of payment

Case mix index

created by MS-DRG system - a hospital's case mix index (types or categories of patients treated by the hospital) is based on the relative weights of the MS-DRG. Can be found by multiplying the relative weights of each MS-DRG by the number of discharges within that MS-DRG.

Operation Restore Trust

1995 joint effort of the DHHS, OIG, CMS and AOA to target fraud and abuse among healthcare providers

Coding Compliance Plan

component of and HIM compliance plan or a corporate compliance plan that focuses on the unique regulations and guidelines with which coding professionals must comply

Packaging

a payment under Medicare outpatient prospective payment system thatincludes items such as anesthesia, supplies, certain drugs and the use of recovery and observation rooms

UB-04

USED BY HOSPITALS

single standardized Medicare form for standardized uniform billing, implemented in hospital inpatient and outpatient in 2007; also supposed to be used by major third-party payers

CMS-1500

USED BY PHYSICIAN'S OFFICES

universal insurance claim developed and approved by the AMA and CMS. Physicians use it to bill Medicare, Medicaid and insurance providers

Allowable fee

average or maximum amount the third-party payer will reimburse proviers for the service

CPR

CUSTOMARY, PREVAILING AND REASONABLE - type of retrospective method in which the third-party payer pays for fees that are customary, prevailing and reasonable

UCR

USUAL, CUSTOMARY AND REASONABLE - type of retrospecive fee-for-service method in which the third-party payer pays for fees that are usual, customary and reasonable, wherein "usual" means "usual for the individual provider's practice", "customary" means "customary for the community" and "reasonable" means "reasonable for the situation"

Global payment

form of reimbursement used for radiological and other procedures that combines the professinal and technical components of the procedures and disperses payments as a lump sum to be distributed between the physician and the healthcare facility

Prospective payment system (PPS)

type of reimbursement system that is based on preset payment levels rather than actual charges billed after the service has been provided; specifically, one of several Medicare reimbursement systems based on predetermined payment rates or periods and linked to the anticipated intensity of services delivered as well as the beneficiary's condition

PMPM

Per member (or patient) per month - type of managed care arrangement by which providers are paid a fixed fee in exchange for supplying all of the healthcare services an enrollee needs for a specified period of time (usually a month but can be a year)

Capitated rate

method of payment where the reimbursement is a fixed, per capita amount for a period

Traditional (fee-for-service reimbursement)

reimbursement method involving third-party payers who compensate providers after the healthcare services have been delivered; payment is based on specific services provided to all subscribers

Episode-of-care reimbursement (EOC)

category of payments made as lump sums to providers for all healthcare services delivered to a patient for a specific illness and/or over a specified time period; also called BUNDLED PAYMENTS because they include multiple services and may include multiple providers of care

Per diem

type of prospective payment method in which the third-party payer reimburses the provider a fixed rate for each day a covered member is hospitalized

Traditional retrospective

type of fee-for-service reimbursement in which providers receive recompense after health services have been rendered

Case-based

type of prospective payment method in which the third-party payer reimburses the provider a fixed, preestablished payment for each case

Resource-based relative value scale (RBRVS)

Medicare reimbursement system implemented in 1992 to compensate physicians according to a fee schedule predicated on weights assigned on the basis of the resources required to provide the services

Managed care

payment method in which the third-party payer has implemented some provisions to control the costs of healthcare while maintaining quality care

Relative value (unit - RVU)

number assigned to a procedure that describes its difficulty and expense in relationship to other procedures